Overview of TBI Flashcards
What is an Acquired Brain Injury (ABI)
Not hereditary, congenital, degenerative, or induced by birth trauma
Results in changes in neuronal activity affecting the physical integrity, metabolic activity, or functional ability of neurons
What is a Traumatic Brain Injury (TBI)?
Injury caused by external forces
Impact to the head directly (traumatic impact)
Inertial forces that damage the brain (traumatic inertial)
What is a Nontraumatic Brain Injury (NTBI)?
Caused by internal factors
Examples (Anoxia/hypoxia, Exposure to toxins, Infections, Pressure from tumor, Stroke)
What are the two types of TBIs?
Traumatic IMPACT: Impact to the head directly
Traumatic INERTIAL: Inertial forces that damage the brain
How many (around about) ED visits are related to TBI-related causes?
2.8 million in on year (56,800 deaths)
Increased 54% in 8 years
What are the top 3 causes of TBI related injuries?
1: falls (48%): most are children and older adults
Intentional self-harm was the second leading cause of TBI-related deaths alone (33%)—leading cause for ages 45–64 years old
Who is at highest risk to get a TBI and be hospitalized?
American Indian/Alaska Native
Who is at highest risk to not get follow up care?
Racial and ethnic minority groups (non-Hispanic black and Hispanic)
Poorer psychosocial, functional, and employment outcomes
Who has the worst outcome related to TBIs?
Persons in correctional facilities, those who are homeless, survivors of partner violence, service members/veterans, persons with lower incomes/health insurance, rural
What are some risk factors for TBI?
Younger (0–4, 15–19) or elderly (75 and older)
Male
Lower SES
Psychiatric diagnosis
Dementia
Contact sports, not using helmets
What are the five criteria to classify injury severity?
Structural Imaging
Loss of consciousness
Alteration of Consciousness/mental state
Post-traumatic amnesia
Glasgow coma scale
What are the TBI serverities?
Mild (minutes to hours)
Moderate (minutes to days)
Severe (hours to days)
What is Posttraumatic Amnesia (PTA)?
A period of disorientation and difficulty consistently making new memories
What is considered the resolution of PTA?
Consistently oriented and able to make new memories
What are the components of the Glasgow Coma Scale?
Eye opening (1-4)
Motor Response (1-6)
Verbal Response (1-5)
Is a higher score on the Glasgow Coma Scale good or bad?
Good! Highest score is 15
Lowest score possible is 3 and is the worst
What are some posturing examples?
Decorticate: Elbow and wrist flexion, toe/ankle extension
Decerebrate: Elbow extension and wrist flexion, toe/ankle extension
(cErEb - Elbow Extension)
Can posturing be one sided?
Yes!
Associated with one hemisphere compression
What is the cause of decorticate posturing?
Bilateral damage to diencephalon-upper midbrain
What is the cause of decerebrate posturing?
Bilateral damage to upper midbrain
What if someone is presenting with no upper extremity movement and there’s a Babinski response at the toes on the same side?
one entire hemisphere compression ofdiencephalon
Pre-existing factors that can interfere with GCS?
Language or cultural differences
Intellectual or neurological deficit
Hearing loss or motor speech impairments
What are some effects of current treatment that can interfere with GCS?
Physical (e.g., intubation or tracheostomy)
Pharmacological (e.g., sedation or paralysis0
What are some effects of other injuries or lesion that can interfere with GCS?
Orbital/cranial fracture
Aphasia or hemiplegia
Spinal cord damage
Describe raccoons eyes
Brusing and swelling of eyes
Periorbital ecchymosis
Basilar skull fracture, more anterior
Describe battle’s signs
Bruising around mastoid/ears
Retroauricular ecchymosis
Basilar skull fracture, more posterior
How is a mTBI defined by the American Congress of Rehabilitation Medicine
Traumatically induced physiological disruption of brain function, as manifested by at least one of the following:
- Any period of loss of consciousness
- Any loss of memory for events immediately before or after the accident
- Any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused)
- Focal neurological deficit(s) that may or may not be transient, but where the severity of the injury does not exceed the following: Loss of consciousness of approximately 30 minutes or less. After 30 minutes, an initial Glasgow Coma Scale (GCS) of 13–15, Posttraumatic amnesia (PTA) not greater than 24 hours
What are the causes/pathophysiologies for primary injury
Axonal shearing (diffuse axonal injury)
Contusion
Epidural hematoma (EDH)
Subdural hematoma (SDH)
Subarachnoid hemorrhage (SAH)
Hypoxic-ischemic
What is a Coup-Contrecoup injury?
Coup is the initial injury
Contrecoup is the secondary injury/impact
Brain occurring injury at front and back as it moves in the skull
What is a diffuse axonal injury?
Widespread shearing and retraction of damaged axons
Sudden acceleration then deceleration of brain
Shaken baby syndrome
Result of to Coup-Contrecoup
Causes from gray and white matter having different levels of stiffness
What is a Contusion?
Bruise on the brain
Result of to Coup-Contrecoup
What is a Epidural hematoma (EDH) and how does it present?
Collection of blood between dura and cranium
Brief loss of consciousness followed by lucid interval, then headache, obtunded, hemiparesis - can be deadly
What is a Subdural hematoma (SDH) and how does it present?
Collection of blood between the dura mater and arachnoid mater
Headache, altered mental status, hemiparesis
Can cause a midline shift
Major differences between SDH and EDH
Blood flow!
EDH - Artery (rapidly expanding)
SDH - Venous blood (slowly expanding)
What is a Subarachnoid Hemorrhage (SAH) and how does it present?
Bleeding into subarachnoid space
Often seen with aneurysms, but can be caused by TBI
What is a Subarachnoid Hemorrhage (SAH) and how does it present?
NTBI
Systemic hypotension
- Result of Anoxia/hypoxia
- Results in Global damage
What are some secondary injuries/pathophysiology associated with TBIs?
Cerebral herniation
Ischemic CVA from vascular compression
Excitotoxicity
Apoptosis - cell death
Inflammation due to trauma
Coagulopathy - clotting factors reduced for the brain while moving to other injury
What is Intracranial Pressure (ICP) and how does it impact patients?
Increased intracranial pressure
- Abnormality of brain fluid dynamics
- Hematoma
Normal ICP is 4–15 mm Hg
>20mm Hg is enough to alert staff
Monitored with Licox
if increased, herniation of brain
- Supratentorial: uncal, central, cingulate, transcalvarial, tectal
- Infratentorial: upward cerebellar/transtentorial,
tonsillar/downward cerebellar
External Ventricular Drain for fluid management (can be clamped for movement)
What is the primary goal for managing an acute TBI?
Prevent secondary injury by surgical management
Intracranial pressure (ICP) monitoring
Cardiovascular/respiratory support
Management of concomitant injuries
Additional: reverse coagulopathy, DVT/PE prevention, EARLY MOBILIZATION, nutrition
When would surgical intervention be warrented?
Reduce depressed skull fracture
Remove penetrating bodies if accessible
EDH/SDH
- Craniotomy/craniectomy (Cryopreservation or subcutaneous storage followed by cranioplasty)
- Burr hole/catheter
Name some red flags for TBI management
Progressively declining level of consciousness
Progressively declining neurological examination (neurocognitive, neurobehavioral)
Pupillary asymmetry
Seizures
Repeated vomiting
Double vision
Worsening headaches
Cannot recognize people or disoriented to place
Behaves unusually or seems confused and irritable
Slurred speech
Unsteady on feet
Weakness or numbness in arms/legs
What are some biomedical complications that can occur?
Include but not limited to:
-Seizures
- Sympathetic “storming”
- Hydrocephalus
- Heterotopic ossification (inflammation reaction)
- Venous thromboembolism (DVT, PE)
Describe Seizures
Electrical disturbance in the brain
Risk factors: hydrocephalus, intracranial hemorrhage, depressed skull fracture, hematoma evacuations, low GCS, dural penetration, parietal lesions, focal neuro deficits
Multiple types (e.g., generalized with impaired awareness, focal awareness)
May be “subclinical” (may not even know they are occurring)
Describe sympathetic “storming”
Also known as paroxysmal sympathetic hyperactivity (PSH), dysautonomia
Uninhibited sympathetic outflow after CNS injury
Cycling of agitation/dystonia
- Tachycardia, tachypnea, hypertension, hyperthermia, diaphoresis/hyperhidrosis, posturing
- Diagnostic PSH-AM scal
Describe Hydrocephalus
CSF accumulation in the ventricles (brain swelling that can lead to brain herniation)
May note the following:
- Papilledema: pressure causes optic nerve swelling
- Decreased consciousness
- Memory deficits
- Headache
- Focal neurological deficits
What are the domains within the constellation of impairments?
Physical: abnormal tone, sensory deficits, decreased motor control/learning, paresis/paralysis, impaired balance, spasticity, etc.
Behavioral
Emotional
Cognitive
What are some ways to measure/describe BI recovery/progress?
Rancho Los Amigos Levels of Cognitive Functioning (LOCF)
Disability Rating Scale (DRS)
Glasgow Outcome Scale: Extended
How main levels are within the LOCF?
8 or 10 levels
Levels of assistance are included on 10 level
Lower the level: more assistance and decreased response
When does the DRS get administered? and what is included?
Administered within 72 hours after rehab admission and within 72 hours before discharge
Eye-opening communication ability, motor response, cognitive ability for feeding, toileting, and grooming, as well as level of functioning for physical, mental, emotional, or social function, and employability
When does the Glasgow Outcome Scale: Extended get administered? and what is included?
Administered at 3, 6, and 12-month marks
Consciousness, independence inside and outside of home, social and leisure activities, family and friendships
